State of Rhode Island and Providence Plantations
DEPARTMENT OF BUSINESS REGULATION
Division of Commercial Licensing and Racing and Athletics
REAL ESTATE APPRAISERS SECTION John O. Pastore Center, Bldg. 69-1 1511 Pontiac Avenue Cranston, RI 02920-0942 Tele: (401) 462-9506 Fax: (401) 462-9645 www.dbr.state.ri.us
REAL ESTATE APPRAISERS COMPLAINT FORM
Complainant’s Name: Residence: LAST FIRST CITY/TOWN MIDDLE STATE ZIP
STREET
Mailing Address: Home Telephone
(If different from residence) Business Telephone & Extension
Name, address, and phone number of person who always knows where to contact me. Licensee(s) about whom or which I am making complaint: Name Address (Business or Residence)
Phone
List section(s) of Law(s) or Rule(s) violated (if known). State concisely the basis of your complaint:
Please attach an additional narrative explaining your allegations. Submit all documents relative to this complaint. Date, time, and place of alleged violation: Other federal, state, municipal, local agencies or legal counsel I have contacted with regard to this complaint including results of contacts.
The undersigned swears to or affirms the truth and accuracy of all statements, answers, representations and allegations contained herein, including all statements hereto attached. Signed: Subscribed and sworn to at A.D. 20 . Date: Before me this day of
NOTARY PUBLIC Office Use Only: Case No.
Date Received:
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